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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602870
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:44:11 PM


Document Has Been Signed on 01/30/2024 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SERENTO CASAFACILITY NUMBER:
198602870
ADMINISTRATOR:SARAH SESAYFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 20DATE:
01/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Heather O'NeelTIME COMPLETED:
03:58 PM
NARRATIVE
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During the course of inspecting the facility memory care fire doors for safety, LPA and staff observed the two fire doors inside are a few seconds off and open at 17 seconds instead of 15. Also the fire door in the courtyard is not operating properly. The door opens immediately and then alarm sounds off which is a health and safety hazard for residents in care.

Based on observation, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The deficiency is being cited on the attached LIC 9099D.


Deficiency cited.

Exit interview and copy of report, 809D and appeal rights provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/30/2024 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SERENTO CASA
FACILITY NUMBER: 198602870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2024
Section Cited
CCR
87303(a)

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87303 (a)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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Facility will contact fire department, repair all three doors and test them to make sure they function properly and send a written plan to LPA addressing how the facility plans to safeguard the residents from awoling until doors are repair. POC is due 01/31/2024 for written plan.
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The fire door that leads to the courtyard does not function properly and opens without delay. Two fire doors inside the memory care unit are delayed for more time that the 15 seconds which poses/posed a health and safety issue for persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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